Comparing ST-segment elevation myocardial infarction care between patients residing in central and remote locations: a retrospective case series.

People who experience an ST-elevation myocardial infarction (STEMI) due to an occluded coronary artery require prompt treatment. Treatments to open a blocked artery are called reperfusion therapies (RTs), and can include intravenous pharmacological thrombolysis (TL) or primary percutaneous coronary intervention (pPCI) in a cardiac catheterisation laboratory (cath lab). Optimal RT (ORT) with pPCI or TL reduces morbidity and mortality. In remote areas, a number of geographical and organisational barriers may influence access to ORT. These are not well understood, and the exact proportion of patients who receive ORT - and the relationship to time of day and remoteness from the cardiac cath lab - is unknown. The aim of this retrospective study was to compare the characteristics of ORT delivery in central and remote locations in the north of Scotland, and to identify potential barriers to optimal care with a view to service redesign. The study was set in the north of Scotland. All patients who attended hospital with a STEMI between March 2014 and April 2015 were identified from national coding data. A data collection form was developed by the research team in several iterative stages. Clinical details were collected retrospectively from patients' discharge letters. Data included treatment location, date of admission, distance of patient from the cath lab, route of access to health care, left ventricular function and RT received. Distance of patients from the cath lab was described as remote if they were more than ninety minutes of driving time from the cardiac cath lab, and described as central if they were ninety minutes or less of driving time from the regional centre. For patients who made contact in a pre-hospital setting, ORT was defined as pre-hospital TL (PHT) or pPCI. For patients who self-presented to the hospital first, ORT was defined as in-hospital TL or pPCI. Data were described as mean (standard deviation) as appropriate. Chi-squared and student's t-test were used as appropriate. Each case was reviewed to determine if ORT was received; if ORT was not received, the reasons for this were recorded to identify potentially modifiable barriers. Of the 627 acute myocardial infarction patients initially identified, 131 had a STEMI, and the others were non-STEMI. From this STEMI cohort, 82 (62%) patients were classed as central and 49 (38%) were remote. In terms of initial therapy, 26 (20%) received pPCI, 19 (15%) received PHTs, 52 (40%) received in-hospital TL, while 33 (25%) received no initial RT. ORT was received by 53 (65%) central and 20 (41%) remote patients; chi-squared = 7.05, degrees of freedom = 130, p < 0.01).Several recurring barriers were identified. This study has therefore demonstrated a significant health inequality between the treatment of STEMI in remote locations compared to central locations. Potential barriers identified include staffing availability and training, public awareness and inter-hospital communication. This suggests that there remain significant opportunities to improve STEMI care for people living in the north of Scotland

Anatomy of corruption in humanitarian assistance: a retrospective analysis of emergency response operations of the Liberia Red Cross Society (LRCS) to the Ebola Virus Disease (EVD) outbreak in Liberia (2014 – 2016)

This study critically explores the pervasive issue of corruption in humanitarian assistance, focusing on the Liberia Red Cross Society (LRCS) during the Ebola outbreak in Liberia from 2014-2016. For a country grappling with broken infrastructure and fragile healthcare systems due to a 14-year-long civil war, the Ebola crisis in Liberia was an unprecedented disaster as evidenced by 10,672 recorded cases and 4,808 reported fatalities between 2014 and 2016. The LRCS was a prominent local humanitarian actor in the Ebola response and recovery efforts, but its work was marred by corruption stemming from organizational, contextual, and motivational factors. This study sheds light on the nature and extent of corruption within humanitarian action from the perspective of the LRCS and the Ebola epidemic in Liberia, contributing to humanitarianism as a discipline and a profession. The study utilized the principal-agent theory and the organizational culture theory of corruption in humanitarian assistance, which had been employed in earlier studies of a similar nature. In terms of methodology, a qualitative approach with retrospective review was employed to address two research questions regarding the drivers and impact of corruption in the Ebola response and recovery operations conducted by the LRCS. Data for the study were collected from a mix of 14 pre-existing sources, including documents originating from the LRCS and its consortium of donors and partners, as well as published news content from notable local and global media outlets. The results were generated through document analysis facilitated by ATLAS.ti, a qualitative data analysis software, which considered patterns, trends, and insights within the sources gathered for the study. Multiple rounds of analyses on the data were conducted to validate the results of the study.  The findings of this study reveal a complex web of corruption within humanitarian aid delivery during crisis and disaster. Corrupt practices within the LRCS included fraud and misuse of Ebola relief funds and resources, driven by individual motivations coupled with a number of organizational and contextual factors. The corruption had adverse effects on the efficiency, effectiveness, and accountability of relief efforts, potentially leading to reduced donor confidence in the LRCS and funding reduction. The study also stresses the importance of leadership, decision-making processes as well as resource management in preventing or enabling corruption within humanitarian aid organizations. These findings underscore the need for robust internal oversight, accountability mechanisms, and ethical leadership in humanitarian organizations to prevent and address corruption effectively

Anatomy of corruption in humanitarian assistance: a retrospective analysis of emergency response operations of the Liberia Red Cross Society (LRCS) to the Ebola Virus Disease (EVD) outbreak in Liberia (2014 – 2016)

This study critically explores the pervasive issue of corruption in humanitarian assistance, focusing on the Liberia Red Cross Society (LRCS) during the Ebola outbreak in Liberia from 2014-2016. For a country grappling with broken infrastructure and fragile healthcare systems due to a 14-year-long civil war, the Ebola crisis in Liberia was an unprecedented disaster as evidenced by 10,672 recorded cases and 4,808 reported fatalities between 2014 and 2016. The LRCS was a prominent local humanitarian actor in the Ebola response and recovery efforts, but its work was marred by corruption stemming from organizational, contextual, and motivational factors. This study sheds light on the nature and extent of corruption within humanitarian action from the perspective of the LRCS and the Ebola epidemic in Liberia, contributing to humanitarianism as a discipline and a profession. The study utilized the principal-agent theory and the organizational culture theory of corruption in humanitarian assistance, which had been employed in earlier studies of a similar nature. In terms of methodology, a qualitative approach with retrospective review was employed to address two research questions regarding the drivers and impact of corruption in the Ebola response and recovery operations conducted by the LRCS. Data for the study were collected from a mix of 14 pre-existing sources, including documents originating from the LRCS and its consortium of donors and partners, as well as published news content from notable local and global media outlets. The results were generated through document analysis facilitated by ATLAS.ti, a qualitative data analysis software, which considered patterns, trends, and insights within the sources gathered for the study. Multiple rounds of analyses on the data were conducted to validate the results of the study.  The findings of this study reveal a complex web of corruption within humanitarian aid delivery during crisis and disaster. Corrupt practices within the LRCS included fraud and misuse of Ebola relief funds and resources, driven by individual motivations coupled with a number of organizational and contextual factors. The corruption had adverse effects on the efficiency, effectiveness, and accountability of relief efforts, potentially leading to reduced donor confidence in the LRCS and funding reduction. The study also stresses the importance of leadership, decision-making processes as well as resource management in preventing or enabling corruption within humanitarian aid organizations. These findings underscore the need for robust internal oversight, accountability mechanisms, and ethical leadership in humanitarian organizations to prevent and address corruption effectively

Pre-Hospital ECG E-Transmission for Patients with Suspected Myocardial Infarction in the Highlands of Scotland

Patients with ST elevation myocardial infarction (STEMI) require prompt treatment, best done by primary percutaneous coronary intervention (PPCI). However, for patients unable to receive PPCI, immediate pre-hospital thrombolysis (PHT) is the best alternative. Evidence indicates that diagnostic and management support for staff increases the use of PHT. This study aimed to describe the patient demographics and management of patients, to determine any potential inter-area differences in referral rates to the ECG e-transmission service and to explore the views and experiences of key staff involved in ECG e-transmission within NHS Highland. Data from 2,025 patient episodes of ECG e-transmission identified a statistically significant geographical variation in ECG e-transmission and PHT delivery. Scottish Ambulance Service (SAS) staff were more likely than GPs to deliver PHT overall, however, GPs were more likely to deliver in remote areas. Interviews with six Cardiac Care Unit (CCU) nurses and six SAS staff highlighted their positive views of ECG e-transmission, citing perceived benefits to patients and interprofessional relationships. Poor access to network signal was noted to be a barrier to engaging in the system. This study has demonstrated that a specialist triage service based on e-transmission of ECGs in patients with suspected STEMI can be implemented in a diverse geographical setting. Work is needed to ensure equity of the service for all patients

Primary PCI and the role of the 'thrombolysis nurse' : Threat or opportunity

While particular titles and job roles vary, acute cardiac nurses or ‘thrombolysis nurses’ have been highly influential in ensuring patients with ST-segment elevation myocardial infarction receive thrombolysis therapy with the minimum delay. If primary percutaneous coronary intervention (PCI) replaces thrombolysis as the chief reperfusion treatment in the UK in future—which seems likely—then this will inevitably have implications for those nurses for whom thrombolysis activity is a key responsibility. This paper explores some of these issues and discusses potential opportunities related to this change in reperfusion services